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Breast
Implant Revision Surgery ~ Breast Augmentation Redos
by Don
R. Revis, Jr., MD, FACS of Fort Lauderdale, FL
Almost
250,000 women underwent breast augmentation during 2002, and a significant
number of these women will, at some point in the future, require another
operation related to her breast implants. Breast augmentation is a
procedure that is often assumed to be simple in nature and execution
but is actually quite complex. Proper surgical technique and attention
to detail are essential to good results, and too often these are overlooked.
As
a similar example, twenty years ago rhinoplasty was treated the same
way, and the usual result was that every nose done by the same plastic
surgeon turned out to look exactly the same, regardless of the patient's
facial proportions, preferences, ethnic background, etc. Over the
past twenty years an evolution in our thought processes has resulted
in the realization that rhinoplasty is a multidimensional, complex
surgery that must be individualized for each patient. Breast augmentation
is long overdue for such an evolution (revolution) as well. For instance,
the notion that the surgeon knows best in the selection of the implant
size for his or her patients is ridiculously outdated. We should never
presume to know what is best for our patients in this regard. Our
responsibility is to present the facts to our patients and guide them
in making their own decision that is in their best interests. Similarly,
no one incision is right for every patient, and one location for implant
placement (be it above the muscle, subpectoral, or totally submuscular)
does not satisfy every patient's needs.
The
three most common reasons for breast implant revisions- changing implant
size, improving the natural feel and appearance of the breasts, and
correcting capsular contracture- should be minimized by a careful
and thorough approach to breast augmentation. Dr. Revis has developed
a systematic approach that has minimized these revisions in his own
practice while improving patient outcomes and satisfaction ratings.
He feels that the real focus should be in prevention of these problems
rather than in their treatment. However, breast implants are like
any other man-made implantable medical device (such as heart valves
and artificial joints), and realistically some patients will require
revisionary procedures. Plastic surgeons must be aware of the potential
problems that may exist and be equipped to properly diagnose and treat
patients so that an acceptable outcome is achieved.
The
role of the plastic surgeon in approaching breast augmentation revisions
should be to properly evaluate the problem and to recommend one or
more ways in which the problem can be corrected. Breast augmentation
revision surgery is certainly more complex than primary (initial)
augmentation, and you should realize that the proper time for the
correct operation to be performed is the first time.
The
cornerstone of your plastic surgeon’s approach should be to individualize
your treatment to your specific circumstances and goals and to ensure
that you have an adequate understanding of the issues involved so
that you are able to make a fully informed decision. This will help
you achieve the appearance you desire with the least invasive procedure
available, thus creating a mutually rewarding experience.
Surgeon
Selection
As you consider plastic surgery, one of the most important decisions
you will make is choosing your surgeon. Patients should seek a plastic
surgeon who provides the latest, state of the art cosmetic plastic
surgery in a safe and professional environment. Your surgeon should
be board certified by the American Board of Plastic Surgery, the only
plastic surgery board recognized by the American Board of Medical
Specialties, and a member of The American Society of Plastic Surgeons,
the national governing body representing almost 98% of all board certified
plastic surgeons in this country.
Should
you entrust your revision to your original plastic surgeon? As you
will read, many revisions are not related to a technical problem with
the technique employed by your original plastic surgeon. If you maintain
a good relationship and confidence in your original plastic surgeon’s
abilities, then by all means he or she is a good starting point to
discuss possible solutions for your situation. However, breast augmentation
revisions are typically much more complex than the original operation,
and you should seek several opinions and entrust your safety and your
appearance only in the surgeon in whom you have the most confidence
to achieve your desired results.
The
need for breast augmentation revisions stem from a number of sources
but fall into several broad categories:
The
"Internal Bra"
In
recent years, there has been a dramatic increase in the number of
patients presenting with bottoming out of one or both implants. This
means that the pocket, or capsule, surrounding the implant has enlarged
or stretched under the effects of gravity and have become too low
on the chest wall or rests too far laterally when lying down. This
may cause the appearance to be unattractive and even uncomfortable
when wearing no bra. The implants may hang too low, preventing you
from being comfortable when braless. You may also experience the implants
falling far apart and even into the armpits when lying down.
The
“internal bra” technique has the effect of creating an internal
bra using strong, permanent suture techniques. Using special lighted
retractors, the implant pockets are expanded (capsulotomy) superiorly
and medially, creating room for the implants to be repositioned at
a higher level and closer together- creating better cleavage, a more
youthful shape, and improved fullness in the upper pole of the breast.
After expanding the pockets in these directions, the part of the capsule
that rests laterally and inferiorly (partial capsulectomy) is permanently
removed and sutured closed, thus preventing the implants from resting
too low or falling too laterally to the sides. Permanent sutures are
used for a long-lasting result. These sutures are carefully placed
so that the suture material is never in direct contact with the implants
inside the body.
Decisions
regarding your revision
Breast
implants come in many different types, and they may be placed through
different incisions and in different locations. Once you have decided
to undergo a revision of your augmentation, there are three main choices
you must make- incision location (whether or not your prior incisions
will allow the proper procedure to be performed or if you may need
additional incisions), whether or not your implants will be replaced
and if so then the new implant type and size, and whether or not the
implant pockets will remain the same or be changed. This can be quite
confusing, and the following information is to help you understand
the various issues involved in making your decision.
Types
of Implants- Silicone Gel vs. Saline Filled Implants
There are two basic types of implants, silicone gel and saline filled.
ALL implants consist of a silicone shell. Silicone gel implants are
filled with liquid silicone. The FDA has restricted the use of silicone
gel implants to only a select group of plastic surgeons and only certain
of their patients. If you are interested in having silicone gel implants,
be sure to ask your plastic surgeon if you might be eligible to participate
in one of the FDA-approved protocols. To date, there have been numerous
studies in the medical literature demonstrating no link between silicone
gel implants and any type of disease.
Saline
filled implants consist of an outer shell of silicone that is filled
with saline, or salt water. Most breast implants used for breast augmentation
are of this type. In addition, there is a new type of saline implant
called a "high profile" saline implant. It is designed to
give better breast projection and volume, because more of its volume
is used in establishing projection rather than increasing the width
of the implant.
New
High Profile Saline Implants
We
now have a new implant type to offer our patients, a new saline filled
breast implant called a high profile implant. The high profile implant
provides yet another option for those women considering breast augmentation
to enhance their appearance. These new implants allow a higher volume
to be achieved with a smaller diameter implant. Depending on the shape
of your chest, you may be a candidate for these new implants and may
achieve an improved shape and more natural appearance.
Types
of Implants- Smooth vs. Textured Surfaces
Breast
implants may have a smooth surface or may have a rough, textured surface.
The textured implants were produced in the hopes that they would decrease
the incidence of forming a scar around the implant, also known as
a capsular contracture. This does appear to be effective, but only
when the implant is placed beneath the breast but above the muscle
of the chest wall (see Implant Placement Options, below). Textured
implants have never been shown to provide any advantage over smooth
implants when placed beneath the muscle of the chest wall.
Textured
implants also have their own disadvantages. Textured implants are
manufactured by taking a smooth implant shell and applying the texturing
to the outer surface. This texturing process makes the shell slightly
thicker and more stiff, which translates into an implant that is more
visible through the skin and is more easily felt when the breast is
touched.
Because
of these disadvantages and because most implants are placed beneath
the muscle, the great majority of breast implants used today are of
the smooth variety. Dr. Revis believes that the smooth surfaced implants
provide a much more natural look and feel when compared to textured
implants.
Types
of Implants- Round vs. Anatomical Shaped
Most
breast implants used today are round. There are also implants which
are teardrop shaped, called anatomical implants. These are in an attempt
to better simulate the shape of the natural breast. In certain cases
these may be recommended, but ALL anatomical implants are textured,
with the accompanying disadvantages of textured implants. Please ask
your plastic surgeon if you think you might be a candidate for anatomical
implants.
Incision
Placement
The
incision for breast augmentation may be placed underneath the breast,
around the areola (the pigmented skin surrounding the nipple), in
the armpit, or in the belly button (TUBA approach). Your plastic surgeon
will discuss which might be the best for your specific situation at
the time of your consultation.
Nationally,
most patients choose an incision around the nipple or in the crease
underneath the breast for their initial operation. When performed
properly should in no way prevent breastfeeding or alter nipple sensitivity.
Revisions
typically cannot be performed through an axillary incision or through
a TUBA incision unless only a very simple procedure will be performed
such as changing the size of the implants or replacing a deflated
implant. Most revisions require a periareolar incision for adequate
visualization to provide the most long-lasting results.
Implant
Placement- Subglandular vs. Submuscular
Breast
implants may be placed beneath the tissue of the breast (subglandular),
or may be placed even deeper, beneath the muscle of the chest wall
(totally submuscular). There is also a subpectoral (or partially submuscular)
placement that some surgeons use. The decision is a very individual
one, and it is determined by the natural shape of your breasts and
chest wall muscles.
Whenever
possible, Dr. Revis prefers to place the implants in a totally submuscular
position. Dr. Revis believes that the advantages of placing the implants
completely beneath the muscle of the chest wall greatly improves the
long-term appearance of your breasts following augmentation. This
is for three main reasons. First, mammography is easier and the quality
is better when the breast implant is separated from the breast tissue
by the additional layer of muscle. Secondly, there is a lower incidence
of capsular contracture when the implants are placed totally beneath
the muscle. Capsular contracture occurs when the body produces scar
tissue around the implant. This may change the shape of the implant
and make the breasts asymmetric. Finally, placing the implants beneath
the muscle of the chest wall makes your augmentation appear more natural
because there is more of your own tissue covering the implant, making
it less likely that you will be able to see or feel the implant.
Dr.
Revis believes that an entirely submuscular placement will improve
your long-term results and minimize your potential complications.
Choosing
The Proper Implant Size
This
is one of the most important decisions you will make. Because of this,
your plastic surgeon should take several approaches to help you make
the best decision based on your anatomy, personal preferences, and
the appearance you wish to achieve. Interestingly, in a recent national
survey, over 80% of patients undergoing breast augmentation stated
that a “C” cup was their desired postoperative goal. A “D”
cup was the second most popular request.
Your
plastic surgeon should measure your natural breast and chest shape.
This provides an idea of what size implant will help you achieve the
size you want postoperatively. As implant size increases, so does
the diameter of the implant. There is an implant that will perfectly
match the diameter of your natural breast. Choosing an implant smaller
than your natural breast shape will not provide the proper cleavage
and shape following the procedure. Similarly, choosing an implant
too large for your natural chest shape is more likely to give you
an unnatural appearance.
Unfortunately,
implants do not come in cup sizes. Rather, they are categorized by
the volume of saline (salt water) that they are designed to hold.
There are several reasons for this. First, your final cup size will
be partially determined by your preoperative breast size, and everyone
is different in this regard. Secondly, a "C" cup from one
bra manufacturer is not necessarily the same as a "C" cup
from another manufacturer. Although everyone is built differently
and bras are not manufactured to a set standard, you can expect that
a cup size is approximately 200cc in a person of average height and
average build. If you are tall or have broad shoulders, you can expect
that number to be slightly higher. Similarly, if you are shorter or
have a more narrow chest, you can expect that number to be slightly
lower. Although a desire for a certain cup size is helpful to your
plastic surgeon in guiding you in the selection of the proper implants,
it is more helpful to focus on the shape and appearance that you wish
to achieve.
Using
these three approaches, you will be able to accurately select the
implant that will give you the appearance you desire. When asked about
size postoperatively, over ninety percent of our patients feel they
chose the right size implant to achieve the appearance they envisioned.
The remaining few state that they might have gone larger if they were
to choose again. We almost never hear that a patient wishes they had
chosen a smaller implant. Therefore, if you are debating between two
sizes, it is probably a better decision to opt for the larger size.
Hopefully
the above information has helped to clarify some of the issues surrounding
breast augmentation. The following information will help prepare you
for your procedure.
Type(s)
of Anesthesia
Anesthesia
is an essential part of any surgical procedure and must be performed
safely. General anesthesia is the deepest form of anesthesia. You
are asleep, feel no pain, and will not remember the procedure. This
form of anesthesia is usually not required for breast augmentation
unless the patient specifically requests general anesthesia.
Intravenous
sedation, called “twilight sleep,” is a combination of local
anesthetic administered at the surgical site by your plastic surgeon
and intravenous sedation administered by your anesthesiologist. You
breathe for yourself, but you are in a deep sleep throughout the procedure.
You should feel no pain, and you will not remember the procedure.
An
intermediate form of anesthesia, the laryngeal mask airway (LMA),
is a relatively new technique. This technique is similar to twilight
sleep in that you are breathing on your own, but the method of sedation
differs. With an LMA, you actually breathe anesthetic gases administered
by the anesthesiologist, rather than receive intravenous sedation
via your intravenous line. These anesthetic gases cause you to sleep
during the procedure. At the completion of the procedure, the gases
are turned off and you wake up from your sleep. You will feel no pain,
and you will not remember the procedure.
The
prevention of postoperative nausea and vomiting is also an important
consideration in our approach to breast augmentation revision surgery.
Zofran is a new drug which is currently the best medication available
to prevent nausea and vomiting. Ask your plastic surgeon about this
medication to make sure that your experience is as pleasant as possible.
Your
plastic surgeon should discuss all of these options with you more
thoroughly at the time of your consultation, and please ask him about
anything you do not understand.
Details
of the Procedure
Breast
augmentation revisions vary greatly in the exact procedure to be performed
and the length of time the operation will last. Your plastic surgeon
should thoroughly describe the procedure he or she has proposed for
you, and please ask questions about anything you do not understand.
After
you are properly anesthetized in the operating room, Dr. Revis injects
a solution of local anesthetics along the borders of the breasts,
underneath the intended incision site, and into the muscle under which
the implants will be placed. This injection solution consists of a
special combination of lidocaine (xylocaine), marcaine (sensorcaine,
bupivicaine) and epinephrine. This accomplishes several objectives.
First, the epinephrine causes vasoconstriction of the area, reducing
your potential for bleeding and bruising. Secondly, the lidocaine
provides a rapid numbing of the area. Although you are asleep, this
prevents the brain from registering any pain from the region during
the operation. Studies have shown that this so-called preemptive analgesia
actually decreases your sensation of pain postoperatively, decreases
the amount and length of time you will need to take pain medication
postoperatively, and also leads to a more rapid return to normal daily
activities. Finally, the marcaine component of this local anesthetic
mixture is a long-acting local anesthetic. This actually prolongs
the numbness of the area, making you more comfortable following surgery
and delaying the time at which you will begin to need any pain medications.
After
the revisionary steps needed in your case have been performed, your
new breast implants are inserted and filled with saline. (Silicone
gel implants come pre-filled and do not require filling in the operating
room). Dr. Revis advocates a “no touch” technique when placing
the implants into the pocket. This includes using new sterile towels
to drape around the breasts, changing his gloves and washing the outer
surface of these new gloves in sterile saline, and only opening the
sterile implant packaging immediately prior to insertion. Dr. Revis
is the only person who ever touches the implants, and his goal is
to minimize the time the implant is exposed to the air in the operating
room prior to insertion into the pocket. Additionally, Dr. Revis does
not allow the implant to come into contact with any instruments or
the skin during the insertion process. He feels that this minimizes
the possibility of any foreign material coming into contact with the
implant and causing any inflammation.
During
the filling process, Dr. Revis advocates the use of a "closed
system" to fill the implants with saline. This means that the
saline that enters the implant is never at any time exposed to the
air in the operating room. The saline flows from a sterile bag through
a sterile tubing directly into the implant. This additional precaution
prevents any foreign material from inadvertently being injected inside
the implant.
After
the implants have been filled properly and your plastic surgeon has
assessed your final shape and size, the incisions are carefully closed
to minimize your scar. A sterile dressing is applied to the incisions,
and a soft surgical bra is placed over your breasts.
After
Your Procedure
Breast
augmentation revisions are typically performed as an outpatient procedure.
After recovering in the recovery room for approximately one hour,
you will be able to go home in the company of a friend or family member.
Ask
your plastic surgeon about his or her recommendations regarding showering,
activity levels, massaging and the use of Mederma (a topical cream
to improve the appearance of your scars) and antibiotics.
You
may also be a candidate for a revolutionary new product for the management
of postoperative pain, called the On-Q Post-Operative Pain Pump. Be
sure to ask your plastic surgeon about this during your consultation
if you think you might be a good candidate for this system.
You
should plan to take it easy following your surgery. No strenuous activities,
heavy lifting (over 20 pounds), aerobic exercises, swimming, contact
sports, tennis, or golf should be planned for the first three weeks.
As your plastic surgeon monitors your recovery, he or she will advise
you when it is safe to resume specific activities.
The
Results You Can Expect
You
will notice an improvement in your breast shape and size immediately.
You may experience soreness in your chest, but this should rapidly
disappear. Any swelling usually takes several weeks to subside. You
should be able to resume your normal daily activities the day after
surgery, and you should be able to resume all of your physical activities
(sports, aerobics, running, etc.) within three to six weeks of surgery.
Re-do
Photo Gallery
Dr. Freund, NY - Dr.
Bazell, IL - Dr.
Chapin, PA - Dr.
Ciaravino - Dr.
Revis, FL - Dr.
Ferraro, NJ
Dr.
Mills, CA - Dr.
Hunstad, NC - Dr.
Hasen, FL - Dr.
Rapaport, NY - Dr. Sorokin, NJ
SURGEONS:
PHOTOS:
DrRevis@SouthFloridaPlasticSurgery.com